Billing- a year and three months later... (update #2) - Page 2

[Midwife Kris]

Originally Posted by morningloria

When my dh called our insurance company, they said they never rec'd a bill from the midwife, and looking at the info the biller faxed over, they are right. The biller sent a bill to a general Blue Cross Boston company, but not ours.

I had a few bills last year that took EONS to get processed because the companies we sent them to would kick it back saying "wrong address, send to ..." Actually send it back to us from the 'right address' telling us to send it back to the same address, then send it back saying 'wrong address', send to a different address. Over and over. Blue Cross was one of those companies! They said 'send it to the address on the card'. Did that and they'd send it back saying it's the wrong address. Even with a verbal over the phone. It's a game.

I still get random checks from one of my client's insurance plans (Blue Cross!) and the baby is TWO. They are not in a hurry to pay, apparently.

I don't know why the biller didn't submit a bill before 11 months had passed, and I don't know why the midwife didn't call us when the entire claim was denied.

Insurance can be billed up to one year from date of birth.

FWIW, not all billers are good at their jobs I found out the hard way.

[morningloria]

another update:

The midwife admitted that she did not submit the info to her biller until 11 months had passed. At that time, the biller submitted the bill to the wrong insurance company and the claim was either denied, or there was no response.

The biller didn't take any other action until Nov 07, which was 1 year after the birth.

The midwife claims that the insurance company is lying, but our insurance plan is excellent. It is a self-administered plan through a union, and we receive benefit statements whenever we go to the doctor. My son went to two different ERs over the same weekend, and the benefit statements arrived within a month.

We pre-authorized and made sure our insurance was going to pay for this homebirth.

So I've let my husband deal with all of this, because I hate anything dealing with money, and the plan is in his name.

The midwife's biller submitted the bill to our insurance company last month and the claim was denied due to time limit.

And, even after all of this, I haven't heard from the midwife AT ALL. She must know that the claim has been denied.

I'm really angry. I feel like she dropped the ball and is trying to make us feel guilty and pay, claiming that the insurance company is being dishonest, when in reality, she and her biller were not on top of it in the first place.

I spoke with a midwife that I work with and she said that our idea of paying what insurance would not have covered is reasonable, the 15%. I would not be offering to pay a full amount to a hospital that had assuming billing responsibility, and I need to treat this the same way.

ugh.

[momileigh]

15%? I'm sorry, I read all the previous posts but don't remember a 15%. I think you should pay her the 20% co-pay. Whoever said that it is insurance fraud for her not to bill you the 20% was right.

Waiting 11 months to bill sounds like somebody who hates paperwork (like me) and puts things off until they get overwhelming, and finally hires someone (the biller) to come in and clean up the mess months later with things piled up like crazy. The biller comes in and does his/her best, but everything is such a mess and now there's a time crunch, so mistakes are made. That is totally *not your fault.* It is a fact that most midwives don't get into the business because they love filing insurance paperwork, but if that's the case, she is able to just not accept insurance. (At this point, that's what I would do if I were starting my own practice... I'd just say, "I don't accept insurance, only cash. You may attempt to get a refund for my services from your insurance company if you like." I know it would really limit my clientele, but I. Hate. Insurance. Paperwork.) But she CHOSE to accept your insurance and then really dropped the ball. I think she may have to bite the bullet and take the percentage from you and learn her lesson. Meanwhile, if I were you, I'd offer her the 20% and your apologies if the rest of the payment doesn't work out. And please, don't tell the insurance company about your little deal about not having to pay the co-pay. That could get her in serious hot water.

And, I just have to add, I think the person who suggested you don't have more children was way, way, way out of line. A ridiculous comment from someone who obviously was carrying a lot of baggage into the conversation. I do hope the stress of this is resolved before you get pregnant again just for your sake!

[jengacnm]

Wow. Guess that midwife doesn't need the money all that bad....11 months??????

Just a note about the 20 percent co pay and insurance fraud-

Let's say my global fee is $3000. That means the client would pay $600 as a co pay.

Now let's say Suzie Q's insurance allows $4000 for global, and pays $4000-$800 co pay=I the midwife get $3200.

So the client doesn't pay the $600, and I still get $200 more than my global fee.

It's legal to charge different insurance companies different global fees. It sounds like it shouldn't be, but my biller had it checked out by a lawyer. And I trust my biller-she "specializes" in midwife billing.

FWIW, I would have charged the 20 percent AND collected the allowed global. And I wouldn't have waited 11 months.....

Back to our regularly scheduled discussion......

[momileigh]

Jenga - whether you charge different global fees for different insurances or not... regardless of how much you net... you still have to charge the client the 20%! Now, you might *wink wink* not really enforce her paying it, but that's still (*wink wink*) insurance fraud.

[christyc]

Originally Posted by morningloria

And, even after all of this, I haven't heard from the midwife AT ALL. She must know that the claim has been denied.

This is troubling to me... She should be in contact with you, given the situation.

[quote]I spoke with a midwife that I work with and she said that our idea of paying what insurance would not have covered is reasonable, the 15%. [QUOTE]

This is what I would do as well-- pay whatever copay the insurance would not have covered anyway. But setting that up would require communication with the midwife.

[morningloria]

momileigh, the 15% came from the midwife telling my husband that we were pre-authorized for 85% coverage.

and luckily for me, my husband got a vasectomy, so I don't have to worry about my "bad karma"- because there are no more babies for us.

also, the midwife admitted that she was going through old paperwork in Sept 07, and realized she never submitted the bill. So it's not like she was overwhelmed or didn't have a biller, she plain forgot.

and I just wanted to add- I think this midwife is wonderful (in every aspect other than billing), and I still refer mamas to her.

Jenga, that makes sense. I don't think of that as fraud either.

[momileigh]

I don't want to sound flippant, but it doesn't matter if you think of it as fraud or not... it is against the law and it is, legally speaking, fraud. I'm sure the people of Enron didn't think of what they were doing as "stealing" either, but that doesn't keep you out of jail. Martha Stewart wasn't out to break any laws or steal any money, she probably just thought she was being smart, and look where her activities landed her.

Furthermore, this may shock you all, but not all midwives are completely respectful of the law all the time. (GASP!!!!!!)

(Actually, most of us have a healthy disrespect for laws that don't seem right to us.... this can be a strength as well as a weakness.)

OK, moving on, looks like she's admitted it was her bad, I think you should pay her the 15% and I think she should be grateful for it, and she learned her lesson for being disorganized. She didn't "just forget" if you ask me, she didn't have an appropriate system in place to be sure it was remembered.

[jengacnm]

Originally Posted by momileigh

Jenga - whether you charge different global fees for different insurances or not... regardless of how much you net... you still have to charge the client the 20%! Now, you might *wink wink* not really enforce her paying it, but that's still (*wink wink*) insurance fraud.

Well, my point is, I wouldn't. I would collect the copay AND the lush allowance. Clients with great insurance only happen along a few times a year.

This midwife thought she was being nice to her client; she likely just needs to be educated. There are legal ways to offer professional courtesy discounts, which I have done for women who work in the field-like the original poster. The way this midwife did it was the simplest but also the most glaringly problematic to an insurance auditor.

[nashvillemidwife]

I would just like to echo, pay your co-pay and not a penny more. God knows I've had my share of clients who try to find a way to screw me and I take a firm stand on making sure I get my money. But in this instance your midwife is the one who stiffed herself by not pursing payment.

Originally Posted by jengacnm

It's legal to charge different insurance companies different global fees. It sounds like it shouldn't be, but my biller had it checked out by a lawyer. And I trust my biller-she "specializes" in midwife billing.

As I understood it, the issue here was that the midwife was jacking up the fee she charged the insurance company while holding the client responsible for a lower amount to ensure the insurance paid her at least 100% of what she wanted to earn without having to collect more than the client. In your instance of a global fee of $3,000 and client has 20% copay, this midwife was billing the insurance $3,800 when her fee is actually only $3,000, she gets paid $3,040 and there's no balance left for the client to pay. That's illegal.